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difficulty.
It was concluded from information gathered from the FDR data and some flight simulations that
when the Vernon airport came into view, the captain misidentified it as the Kelowna Airport
and turned the aircraft to the right to line up with the centreline of Runway 23 at Vernon.
Neither crew member noted that the aircraft heading and the runway heading were 80 degrees
off the intended landing runway, Runway 15, nor did they make effective use of the aircraft’s
navigation system during the approach. The first officer, although unfamiliar with the area, was
aware from his cockpit displays that considerable distance remained to the Kelowna Airport. He
was, however, initially distracted by radio calls with company personnel and was slow to
intervene in the approach to the Vernon Airport.
The crew members were not made aware of the reason that instrument approaches were not
available at the Kelowna Airport, nor did they ask. Had they known it was because the missed
approach paths infringed on the designated fire suppression zone and that all approach aids
were fully functional, they could have completed the NDB B approach, or even the ILS/DME
1 approach with its glideslope guidance, provided they remained in visual meteorological
conditions and did not fly south of the Kelowna Airport.
- 5 -
The following TSB Engineering Branch report was completed:
LP 80/2003 – FDR Analysis
Findings as to Causes and Contributing Factors
1. While executing a visual approach to the Kelowna Airport, the captain misidentified
the Vernon Airport as the Kelowna Airport and executed a visual approach to the
Vernon Airport, descending to 730 feet agl before executing a go-around.
2. The first officer was aware from his cockpit displays that considerable distance
remained to the Kelowna Airport. He was, however, initially distracted by radio calls
and was slow to intervene in the approach to the Vernon Airport.
Findings as to Risk
1. The approach to the wrong airport created a risk of collision with other air traffic and
a risk of landing on an inappropriate runway for the aircraft type.
2. The Air Canada Route Manual contains a visual transition procedure for Runway 33 in
Kelowna, but none for Runway 15. The crew had to improvise a visual approach using
the engine-out procedure chart for Runway 33.
Other Findings
1. After landing at Kelowna, the captain telephoned a supervisory pilot and advised him
that the incident was not significant. The CVR data was, therefore, not secured for the
investigation.
2. The crew members were not aware of the specific reason why instrument approaches
were not available at Kelowna. Had they known the reason, they could have utilized
the Kelowna ILS or NDB for guidance.
3. The Vernon Airport and its ATF are not depicted on any Air Canada Route Manual
Kelowna charts. Should Air Canada crew members find themselves about to infringe
on the ATF zone, they would be unable to find the frequency on which they are
required to broadcast their position and intentions.
- 6 -
Safety Action Taken
Air Canada
Air Canada has extended its “sterile cockpit” concept to prohibit radio communications between
crews and the company when below 10 000 feet, and to emphasise the monitoring of correct
approach parameters.
On 02 June 2004, the TSB sent an Aviation Safety Advisory (615–A040025–1) to Air Canada. The
advisory emphasized the importance of using all available navigation systems to assist in
maintaining situational awareness during visual approaches.
Air Canada’s Flight Safety Department has highlighted this occurrence in the last three issues of
its corporate magazine Flight Safety. Additionally, Air Canada’s internal Flight Safety
Investigative Report has been passed to the Flight Operations Training and Standards personnel
for follow up and minor rule changes. The Airbus A319/320/321 annual recurrent training
program has been altered to highlight this incident and to encourage discussions dealing with
similar situations.
This report concludes the Transportation Safety Board’s investigation into this occurrence. Consequently,
the Board authorized the release of this report on 10 November 2004.
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Appendix A – Track of Air Canada 183
Page No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Rev. No. 6 6 5 5 6 5 5 6 6 5 5 5 5 6
Page No. 15 16 17 18 19 20 21 22
Rev. No. 5 5 5 5 6 5 5 5
DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION
A28NM
Revision 6
Airbus
A319 Model -111 A320 Model -111
A319 Model -112 A320 Model -211
A319 Model -113 A320 Model -212
A319 Model -114 A320 Model -214
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